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COMPLEX PCI 2025

Stent Optimization After Class IA Indication of Imaging-Guided PCI in the 2024 ESC Guideline

In his COMPLEX PCI 2025 lecture entitled "Stent Optimization After Class IA Indication of Imaging-Guided PCI in the 2024 ESC Guideline," Myeong-Ki Hong, MD, PhD (Severance Hospital, Korea), emphasized that post-PCI minimum stent area (MSA) remains the most powerful determinant of clinical outcomes. Before the 2024 update, intravascular imaging was primarily recommended for complex PCI, with optimization encouraged but not strongly mandated. The 2024 ESC chronic coronary syndrome guidelines, however, have upgraded imaging-guided PCI to a Class IA recommendation, formally establishing intravascular imaging as standard of care. He stressed that this upgrade should not be interpreted as an endpoint, noting that imaging itself does not improve outcomes unless it translates into adequate stent optimization. Consistent with this concept, randomized trials such as IVUS-XPL and ULTIMATE demonstrated that PCI meeting IVUS-defined optimization criteria resulted in superior clinical outcomes compared with suboptimal PCI, even when imaging was used in both groups. Expert consensus documents describe multiple optimization targets after stent implantation, including minimum stent area, relative stent expansion, malapposition, tissue prolapse, edge dissection, and reference vessel disease. However, he pointed out that these criteria are often difficult to remember and apply in daily practice. He emphasized that an absolute post-PCI MSA threshold provides the most practical and clinically discriminative criterion. Across landmark trials, an MSA ≥5.5 mm² consistently showed the strongest ability to discriminate long-term clinical outcomes, supporting the concept that, among numerous optimization parameters, achieving an MSA ≥5.5 mm² represents the most reliable and clinically meaningful target for post-PCI optimization. He concluded that in the era of Class IA imaging guidance, the key question is no longer whether to use intravascular imaging, but how well stent optimization is achieved. Among numerous proposed parameters, post-PCI MSA remains the simplest and most clinically meaningful metric to remember, particularly in complex PCI. Live Case 1: Left Main & Multi-Vessel Disease Friday, November 28, 9:00 AM ~ 10:30 AM Main Arena Watch Session Video

January 02, 2026 13550

COMPLEX PCI 2025

Drug-Coated Balloons in Native Coronary Arteries: Hope or Hype?

At COMPLEX PCI 2025, Jung-Min Ahn, MD, PhD (Asan Medical Center, Korea), delivered a comprehensive overview of the current evidence for drug-coated balloons (DCBs) in native coronary artery disease in a lecture entitled "SELUTION, ALLIANCE, OCVC-BIF: DCB in Native Coronary Arteries—Hope or Hype?" DCBs are well established for the treatment of in-stent restenosis and have shown outcomes comparable to drug-eluting stents (DES) in small-vessel coronary disease. However, their role in native coronary arteries remains uncertain. He framed the discussion within the historical evolution of percutaneous coronary intervention, noting that the renewed interest in DCBs reflects a return to drug delivery without permanent metal implantation after decades of stent-based therapy. The REC-CAGEFREE I trial highlighted the limitations of DCB therapy in native coronary disease. In this randomized comparison of paclitaxel-coated balloons and contemporary DES for non-complex de novo lesions, DCB failed to meet non-inferiority at two years (Figure 1). Extended three-year follow-up demonstrated similar rates of cardiac death and target-vessel myocardial infarction between groups, but significantly higher rates of clinically and physiologically indicated target lesion revascularization in the DCB arm (Figure 2). Figure 1. Figure 2. In contrast, the SELUTION DeNovo trial evaluated a strategy of sirolimus-eluting balloon angioplasty with provisional stenting compared with systematic DES implantation. This large, investigator-driven trial randomized patients before lesion preparation and applied broad inclusion criteria. At one year, target vessel failure occurred in 5.3% of patients treated with the DCB strategy and 4.4% of those treated with DES, meeting the pre-specified non-inferiority criterion (Figure 3). Notably, approximately 80% of patients in the DCB strategy group avoided stent implantation, with low and comparable rates of major adverse cardiac events. Five-year follow-up is ongoing. He also reviewed real-world data from contemporary registries. The Swedish SCAAR registry suggested more favorable outcomes with bioadaptor strategies than with DCB in propensity-matched analyses (Figure 4). The GINGER study demonstrated feasibility of sirolimus-eluting balloons in complex de novo lesions but reported numerically higher event rates at one year (Figure 5). Conversely, the Japanese ALLIANCE registry showed favorable one-year outcomes with imaging-guided paclitaxel DCB PCI, emphasizing the importance of careful lesion preparation and routine intravascular imaging (Figure 6). Figure 3. Figure 4. Figure 5. Figure 6. In conclusion, he emphasized that DCB therapy in native coronary arteries should not be viewed as a universal alternative to DES. While early randomized trials underscored important limitations, newer device technologies and strategy-based approaches, such as those evaluated in the SELUTION DeNovo trial, suggest that DCBs may play a selective role in contemporary PCI practice. Ongoing dedicated trials in specific patient populations, including those with large-vessel disease and high bleeding risk, are expected to further clarify whether DCB strategies can achieve outcomes comparable to DES in native coronary artery disease. Special Session: TCT 2025 Hot Issues Thursday, November 27, 5:00 PM ~ 5:50 PM Main Arena Watch Session Video

January 02, 2026 183

COMPLEX PCI 2025

New Evidence for Calcified PCI

Severe coronary calcification poses a major challenge in percutaneous coronary intervention (PCI), often necessitating advanced imaging and specialized plaque-modification strategies to achieve optimal stent expansion and improve clinical outcomes. At the COMPLEX PCI 2025 conference, Ju Hyeon Kim, MD, PhD (Asan Medical Center, Korea), presented important new insights into the management of calcified coronary lesions, highlighting key findings from the VICTORY and ShortCUT trials. He emphasized that severe coronary calcification is strongly associated with stent under-expansion, vessel injury, and suboptimal long-term outcomes. Intravascular lithotripsy (IVL) has emerged as a valuable lesion-modification tool, supported by evidence from pivotal trials such as DISRUPT CAD III and rapid clinical adoption. However, the high cost of IVL remains a significant barrier to widespread use in many healthcare systems. To address the need for comparative data, he presented two randomized trials evaluating more cost-effective alternatives to IVL in calcified lesions. • The VICTORY trial compared the over-pressure non-compliant (OPN) balloon with IVL in patients with heavily calcified lesions. OPN balloon angioplasty achieved stent expansion rates comparable to IVL, with a similar safety profile. • The SHORTCUT trial assessed cutting balloon angioplasty versus IVL in patients with moderate-to-severe calcification. Cutting balloon angioplasty was non-inferior to IVL in achieving post-procedural minimal stent area at the site of maximum calcification. Notably, total procedural cost related to the target vessel was significantly lower in the cutting-balloon arm. Collectively, these randomized trials highlight that cost-efficient strategies such as OPN balloons and cutting balloons may serve as effective alternatives to IVL for appropriately selected patients with calcified coronary disease. As he noted, integrating these data into clinical decision-making may help clinicians tailor lesion-modification approaches that balance efficacy, safety, and economic considerations—ultimately improving care for patients with complex coronary calcification. Special Session: TCT 2025 Hot Issues Thursday, November 27, 5:00 PM ~ 5:50 PM Main Arena Watch Session Video

January 02, 2026 147

COMPLEX PCI 2025

A Practical Strategy for Calcified Coronary Lesions

At COMPLEX PCI 2025, a dedicated workshop on High-Risk PCI and Calcification focused on one of the most critical challenges in contemporary coronary intervention: severe coronary calcification. In the session titled “Cracking the Barrier: Calcium as the Main Obstacle to Successful PCI,” Antonio Colombo, MD (EMO GVM Centro Cuore Columbus, Italy), presented his practical approach to managing calcified coronary lesions. He emphasized that procedural success in calcified lesions depends not on procedural complexity, but on a structured, imaging-guided algorithm and disciplined device selection. Core Devices in Daily Practice Despite the availability of multiple plaque-modifying technologies, he highlighted that real-world practice relies primarily on a limited number of tools. In his experience, more than 90% of calcified lesions can be managed using non-compliant balloons (including super–high-pressure balloons), cutting or scoring balloons, intravascular lithotripsy (IVL), rotational atherectomy and orbital atherectomy. Imaging-Guided Decision Making The cornerstone of his strategy is early intravascular imaging. When calcification is identified on angiography, IVUS or OCT is performed whenever possible. If imaging catheters fail to cross the lesion, rotational atherectomy is promptly adopted, typically using a 1.5–2.0 mm burr, without unnecessary delay. When imaging confirms severe calcification, the choice between rotational atherectomy, IVL, or balloon-based strategies is guided by lesion morphology and vessel characteristics. Calcified nodules require special caution, as aggressive high-pressure balloon dilatation may increase the risk of vessel rupture. In such cases, atherectomy or IVL is preferred when anatomically suitable. A high-pressure non-compliant balloon is routinely used as a final step in lesion preparation. Repeat IVUS or OCT is mandatory to confirm adequate calcium modification. Stenting or drug-coated balloon (DCB) therapy should only be performed after satisfactory imaging results, as implanting a stent in a suboptimally prepared lesion was strongly discouraged. Key Messages He concluded that rotational atherectomy remains the dominant technique for severe coronary calcification, while IVL should be used liberally when available. High-pressure and cutting balloons continue to play an essential role. Above all, intravascular imaging is indispensable—without imaging, optimal treatment of calcified coronary lesions is not achievable. Workshop 5: High-Risk PCI and Calcification Thursday, November 27, 3:30 PM ~ 5:00 PM Main Arena Watch Session Video

December 24, 2025 204

COMPLEX PCI 2025

CTO PCI in 2025: Who Truly Benefits?

At COMPLEX PCI 2025, Ho Lam, MD, FHKAM (Tuen Mun Hospital, Hong Kong, China), challenged attendees to rethink the risks and rewards of Chronic Total Occlusion (CTO) interventions. Presenting a harrowing case of a "Triple CTO," he argued that the question "Who truly benefits?" is best answered not just by randomized data, but by the operator’s ability to master clinical judgment, skills, and device usage to ensure patient safety. The ‘Beast’ of Flow Equilibrium He introduced a case involving a 56-year-old male smoker with a history of hypertension. The patient presented with a severely depressed left ventricular ejection fraction of 20% and a history of cerebrovascular accident due to an LV thrombus. Angiography revealed a daunting "Triple Total" occlusion affecting the LAD, LCX, and RCA. The procedure utilized Impella support to manage the patient's fragile hemodynamics. The team employed a parallel wiring strategy, but after successfully crossing the lesion and opening with a small balloon, the patient experienced a sudden hemodynamic collapse. The culprit was a phenomenon he identified as "Flow Equilibrium." He explained that in critical triple-vessel disease, the heart relies on a delicate balance of collateral supply. By opening the CTO, the antegrade pressure and retrograde pressure equalized, causing a stagnation of flow that led to immediate cardiac arrest, despite the absence of structural complications like perforation or dissection. He illustrated that to break this equilibrium, the operator must speed up the vascularization. The team quickly deployed a stent to increase the antegrade flow force, allowing it to overpower the retrograde resistance and restore perfusion. As predicted, once the stent was placed and the balloon deflated, antegrade flow took over, and blood pressure normalized immediately. Clinical Outcomes Over Randomized Debates The result of the procedure validated the high-risk intervention. Follow-up imaging showed the patient’s ejection fraction improved significantly from a pre-procedural 23% to 40%, with the patient returning to NYHA Class I status. He concluded his lecture by urging interventionalists to "jump out" of the debate regarding randomized data and focus on internal improvement. He outlined three areas that must be developed for successful CTO PCI: Thinking & Clinical Judgment (法): Selecting the right patient and strategy. Skill & Device (術, 器): Utilizing tools like Impella and advanced wiring techniques proficiently. Approach (道): The "Way" to successful revascularization. "Just skill is not enough," he said. "Without the device, without the MCS support, the patient dies hard. Can we do the procedure better so that the patient can get benefit, no failure, no complication? That is the true question." Workshop 4: CTO Thursday, November 27, 2:20 PM ~ 3:30 PM Main Arena Watch Session Video

December 24, 2025 178

COMPLEX PCI 2025

OCTIVUS Trial: OCT- vs. IVUS-Guidance in All-Comer PCI

At COMPLEX PCI 2025, during Workshop 3: Imaging & Physiology, Do-Yoon Kang, MD, PhD (Asan Medical Center, Korea), presented the results of the OCTIVUS Trial, a large-scale randomized study comparing optical coherence tomography (OCT)–guided PCI with intravascular ultrasound (IVUS)–guided PCI in an all-comer population. Intracoronary Imaging: Entering the Class I Recommendation Era He noted that intracoronary imaging has become a central component of contemporary PCI practice. He added that recent clinical guidelines have elevated imaging-guided PCI to a Class I recommendation in several clinical scenarios, including complex lesions and left main disease. Comparison Between OCT and IVUS He explained that optical coherence tomography (OCT) and intravascular ultrasound (IVUS) offer distinct advantages and should be regarded as complementary tools. According to his presentation, OCT provides exceptionally high-resolution visualization of luminal and stent structures, making it particularly valuable for identifying in-stent restenosis and calcified lesions. In contrast, he noted that IVUS allows deeper penetration into the vessel wall and is better suited for the assessment of chronic total occlusions, left main disease, and especially ostial lesions. Overview of the OCTIVUS Trial He then outlined the design of the OCTIVUS trial, describing it as a large-scale, investigator-initiated, pragmatic randomized controlled trial comparing OCT-guided PCI with IVUS-guided PCI in patients with diverse anatomical and clinical characteristics. He stated that the study enrolled adult patients undergoing DES implantation or DCB angioplasty (limited to in-stent restenotic lesions). Major exclusion criteria included STEMI, hemodynamic instability, severe renal dysfunction, inability to advance imaging catheters, and markedly calcified or tortuous lesions. He reported that at the 1-year follow-up, the primary endpoint—target vessel failure, defined as a composite of cardiac death, target-vessel myocardial infarction, or target-vessel revascularization—did not differ significantly between the two strategies. He emphasized that OCT-guided PCI met the predefined criteria for noninferiority compared with IVUS-guided PCI, demonstrating comparable clinical outcomes. Subgroup Analyses He highlighted that predefined subgroup analyses consistently demonstrated similar outcomes between OCT and IVUS across clinically relevant categories. Complex coronary lesions: Among 1,475 patients with left main disease, bifurcations, ostial lesions, CTOs, ISR, or diffuse long lesions, OCT performed comparably to IVUS. True bifurcation lesions: Even in challenging bifurcation disease—including high rates of LM involvement and two-stent techniques—OCT achieved clinical results similar to IVUS. In-stent restenosis (ISR): In ISR lesions, a slight directional trend in favor of OCT guidance was observed, but this should be interpreted with caution and may be attributable to OCT’s greater capability for visualizing neointimal structure Acute coronary syndrome (ACS): In patients with unstable angina or non-STEMI, both imaging modalities again yielded consistent results without evidence of interaction. In conclusion, he stated that the OCTIVUS trial demonstrated that OCT-guided PCI was noninferior to IVUS-guided PCI with respect to 1-year clinical outcomes. He emphasized that OCT showed comparable performance across a broad spectrum of lesion subsets, including complex lesions, in-stent restenosis, bifurcations, and acute coronary syndromes. He concluded that regardless of whether OCT or IVUS is used, appropriate application of intracoronary imaging tailored to lesion characteristics and clinical context leads to improved clinical outcomes. Workshop 3: Imaging & Physiology Thursday, November 27, 1:10 PM ~ 2:20 PM Main Arena Watch Session Video

December 24, 2025 165

COMPLEX PCI 2025

Left Main and Multi-Vessel Disease: Don't Be Trapped by Old Data

At the 10th COMPLEX PCI 2025 in Seoul, Seung-Jung Park, MD, PhD (Asan Medical Center, Korea), delivered a provocative keynote address titled "Guideline-Based Real-World Practice." He boldly challenged the global medical community to stop relying on outdated clinical guidelines and to embrace 'State-of-the-Art PCI'—a modern approach driven by physiology and intravascular imaging—as a superior alternative for Left Main and Multi-Vessel disease. The "Blind Spot" of Current Guidelines: A Legacy of Outdated Trials He began by critically analyzing the evidence base of current international guidelines. He pointed out that the "Class I" recommendations for CABG in patients with multivessel disease, diabetes, or reduced ejection fraction are largely derived from historical trials such as CASS, STICH, SYNTAX, and FREEDOM. "These landmark trials compared medical therapy or surgery against PCI techniques from a bygone era," he noted. "They utilized bare-metal stents or first-generation drug-eluting stents and, most critically, were performed without the guidance of physiology or intravascular imaging." He emphasized that comparing modern surgical outcomes against outdated PCI data creates a distorted view of clinical reality, potentially denying patients less invasive treatment options that are now viable. Era of 'State-of-the-Art PCI' The core of his argument centered on the concept of "State-of-the-Art PCI." He defined this not merely as the implantation of a stent, but as a comprehensive procedural standard that integrates: Physiological Assessment: Using Fractional Flow Reserve (FFR) to precisely identify ischemia-causing lesions and avoid unnecessary stenting. Intravascular Imaging: Utilizing IVUS (Intravascular Ultrasound) or OCT (Optical Coherence Tomography) to ensure optimal stent expansion and apposition. Modern Devices: The use of the latest generation Drug-Eluting Stents (DES). "When we apply these precision tools, the clinical outcomes of PCI improve dramatically," he stated. "We must ask ourselves: if we treat a diabetic multivessel disease patient with 'State-of-the-Art PCI' today, would the results still be inferior to CABG? The old data cannot answer this question." A Paradigm Shift for Left Main and Multivessel Disease Addressing Left Main (LM) coronary artery disease, he highlighted that it should no longer be considered a condition requiring unconditional surgery. "For lesions with low to intermediate anatomical complexity, PCI has already proven its competitiveness," he asserted. He urged the audience to adopt a "Heart Team" approach that respects real-world evidence, where modern PCI offers a safe and effective alternative for high-risk patients who are often poor candidates for surgery. He concluded his lecture by calling for new, large-scale randomized controlled trials (RCTs) that evaluate 'State-of-the-Art PCI' against CABG, ensuring that future guidelines are built on evidence that reflects the current technological landscape. "We must not be trapped by the dogmas of the past," he remarked, setting a progressive tone for the remainder of the conference. "It is time to rewrite the rules based on the precision medicine we practice today." Opening & Workshop 1: Left Main & Multi-Vessel Disease Thursday, November 27, 10:30 AM ~ 12:00 PM Main Arena Watch Session Video

December 19, 2025 226

COMPLEX PCI 2025

DEFINE-DM Trial to Reassess Revascularization in Diabetic Multivessel Disease

At the COMPLEX PCI 2025 meeting, Duk-Woo Park, MD, PhD (Asan Medical Center, Korea), presented the concept and design of the DEFINE-DM trial, a new randomized study designed to reassess revascularization strategies in patients with diabetes and multivessel coronary artery disease. He noted that existing recommendations favor CABG, based on evidence from prior RCTs—such as SYNTAX, BEST, FREEDOM, and BARI-2D—that were conducted before the introduction of current-generation DES, routine intravascular imaging, coronary physiology assessment, and modern antidiabetic agents. He emphasized that PCI practice has changed markedly in recent years, with broader use of IVUS/OCT, FFR-guided lesion selection, and improved stent platforms. In addition, contemporary diabetes therapy, including SGLT-2 inhibitors and GLP-1 receptor agonists, has demonstrated cardiovascular benefits not available during earlier trials. Given these advances, he stated that updated evidence is needed to determine whether PCI can offer comparable outcomes to CABG in appropriately selected diabetic patients. DEFINE-DM is designed to address these gaps. The trial will randomize 1,500 patients with type 2 diabetes and angiographically confirmed three-vessel disease who are suitable for either PCI or surgery. The primary endpoint was defined as the composite of all-cause death, myocardial infarction, or stroke at two years. Based on an estimated 11% two-year event rate in the CABG group for the primary endpoint, he explained that the sample size was determined to provide sufficient power to evaluate the non-inferiority of PCI compared with surgery. Patients assigned to PCI will undergo physiology-guided or imaging-guided intervention using contemporary everolimus-eluting stents. Lesion selection will be guided by FFR or iFR when appropriate, and post-procedure intravascular imaging with IVUS or OCT will be mandated to ensure optimal stent deployment. The combined use of drug-eluting stents and drug-coated balloons will be permitted at the operator’s discretion, and staged PCI will be allowed when clinically indicated. Patients assigned to CABG will undergo surgery within 30 days after randomization, following standard surgical practice with an emphasis on complete revascularization whenever feasible. Use of an internal mammary artery graft to the left anterior descending artery will be strongly recommended, with additional conduit strategies determined by the operating surgeon. All patients in both treatment arms will receive guideline-directed medical therapy, including structured diabetes care and strong recommendations for the use of SGLT-2 inhibitors or GLP-1 receptor agonists. He concluded that DEFINE-DM is expected to provide contemporary data reflecting current PCI techniques and modern medical therapy. “Previous trials do not represent today’s practice,” he said. “DEFINE-DM will help clarify the role of PCI as a potential alternative to CABG in diabetic multivessel disease.” Opening & Workshop 1: Left Main & Multi-Vessel Disease Thursday, November 27, 10:30 AM ~ 12:00 PM Main Arena Watch Session Video

December 19, 2025 162

COMPLEX PCI 2025

Imaging as the Compass: Defining IVUS Criteria for Optimal Left Main Bifurcation Stenting

At the COMPLEX PCI 2025 Workshop on Bifurcation PCI, Jung-Min Ahn, MD, PhD (Asan Medical Center, Korea), brought critical nuance to the long-standing debate over stenting strategies for complex left main (LM) bifurcation lesions. His lecture, titled “Imaging and IVUS-Guided Criteria for Optimal Left Main Bifurcation Stenting,” presented new, data-driven benchmarks for guiding two- and one-stent procedures in unprotected left main coronary artery disease (ULMCAD) using intravascular ultrasound (IVUS). He began by revisiting the established “5-6-7-8” minimal stent area (MSA) rule for LM PCI IVUS guidance introduced by Kang et al. in 2011, acknowledging its clinical value but also its limitations in an era where techniques such as DK crush and IVUS-guided optimization are now the norm. “We need lesion-specific MSA targets,” he said, pointing to recently published multicenter outcomes and ASAN MAIN Registry data which suggest that IVUS-guided MSAs in both provisional and two-stent strategies are predictive of major adverse cardiac events (MACE) at five years. Two-Stent Strategy: Defining Safety Margins Through IVUS Drawing from a 292-patient cohort that underwent IVUS-guided crush technique PCI, he presented statistically validated MSA cutoffs to guide optimal expansion: Distal LM: 11.8 mm² (p = 0.24) LAD ostium: 8.3 mm² (p = 0.002) LCX ostium: 5.7 mm² (p = 0.005) Crucially, dual underexpansion—defined as not achieving the MSA thresholds in both LAD and LCX—was associated with significantly higher MACE rates, reinforcing the need for intravascular optimization regardless of stent count. “It’s not about choosing between one or two stents,” he emphasized, “but ensuring you deliver a physiologically meaningful result in both branches.” One-Stent Crossover Strategy: IVUS Is Not Optional In a parallel analysis of 829 patients treated with LM-to-LAD crossover using a single stent, he outlined a different MSA threshold hierarchy: Proximal LM: 11.4 mm² (p < 0.001) Distal LM: 8.4 mm² (p = 0.005) Proximal LAD: 8.1 mm² (p = 0.013) These numbers were derived from the EuroIntervention 2025 study, and showed that even with a single-stent strategy, underexpansion in two segments independently predicted poorer 5-year outcomes. This finding highlights the importance of systematic IVUS pullbacks both before and after stenting, particularly in LM bifurcation lesions classified as Medina 1,1,1 or 0,1,1. Pre-Stenting LCX Assessment: The True Decision Driver Notably, he introduced an unpublished algorithm based on pre-stenting IVUS of the LCX ostium, defining high-risk lesions as those with a minimal lumen area (MLA) < 3.8 mm² or plaque burden (PB) ≥ 57%. Patients with these characteristics showed significantly higher LCX compromise rates post-provisional stenting—even when side branch dissection or lesion length were not predictive factors. “LCX ostial plaque burden, not angiographic appearance, should guide whether a second stent is needed,” he stressed. In patients with both low-risk IVUS profiles and good crossover expansion, one-stent strategies performed equivalently to two-stent techniques. Conversely, in the high-risk group, two-stent strategies led to superior outcomes only when underexpansion was avoided—again highlighting optimization over technique. Summarizing his findings, he proposed a practical imaging-guided treatment algorithm for LM bifurcation PCI: Perform pre-stenting IVUS of LCX. Apply the 3.8 mm² / 57% MLA-PB thresholds. Use IVUS-defined MSA targets to optimize whichever technique is selected. Consider early two-stenting in high-risk LCX ostium cases only if adequate expansion can be assured. He concluded, “In bifurcation PCI, imaging is not just supportive—it’s decisive.” The lecture underscored that with tailored intravascular imaging and lesion-specific expansion criteria, the choice between one or two stents becomes less philosophical and more anatomical. This data-driven, physiology-informed approach offers clinicians a roadmap to reducing ambiguity in bifurcation PCI, ultimately improving patient outcomes through precision-based interventional cardiology. Workshop 2: Bifurcation Thursday, November 27, 12:00 PM ~ 1:10 PM Main Arena Watch Session Video

December 19, 2025 168

SEOUL VALVES 2025

Out-of-the-Box Solutions for Mitral Valve Repair and Replacement

At the 14th SEOUL VALVES 2025 meeting, during the Keynote Session: Cutting-Edge Innovations in Valve Therapies II, Eberhard Grube, MD (University Hospital Bonn, Germany), presented an overview of emerging innovations in the treatment of mitral valve disease, under the theme “Out-of-the-Box Solutions for Mitral Valve Repair and Replacement.” He emphasized the need for new strategies beyond conventional surgery and transcatheter edge-to-edge repair (TEER), and highlighted novel technologies currently under investigation. He began by revisiting the long-standing challenges of mitral regurgitation (MR) management, stressing the importance of early intervention to reduce regurgitation, promote reverse remodeling, and keep future treatment options open. Recent evidence, including 5-year outcomes from the COAPT trial, showed durable benefits of TEER in secondary MR. However, he underscored its limitations: achieving MR reduction alone may not be sufficient, and outcomes remain suboptimal in certain patient subsets. This has prompted exploration of novel concepts offering solutions for anatomies unsuitable for conventional TEER or surgery. He reviewed several investigational devices: the Half Moon system, designed to provide coaptation augmentation with a contoured baffle; the SUTRA, 3 Leaflet Hemi-Valve for posterior leaflet restoration; the Polares MRace device, offering active posterior leaflet replacement with encouraging early clinical results; and the CARLEN device (Transcatheter Cardiac Leaflet Enhancer), which enables wide and deep coaptation in functional MR across varied anatomies. First-in-human experiences demonstrated procedural feasibility and early reductions in MR, although long-term outcomes are still under evaluation. In closing, he emphasized that mitral valve disease remains “messy and complicated,” and that innovation requires the courage to move beyond established approaches. He concluded that while TEER remains the gold standard today, out-of-the-box solutions such as leaflet augmentation or hemi-valve replacement could expand the range of therapeutic options for challenging MR anatomies in the near future. Keynote Session: Cutting-Edge Innovations in Valve Therapies II Friday, August 8, 1:00 PM-2:00 PM Main Arena, B2 Watch Session Video

September 05, 2025 16875

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